The difference between a fall due to ill health, and a genuine accidental fall, would determine whether a claim under an accident insurance policy is payable or not.
Case Study: Kishan Lal Jain suffered a fall in his bedroom on March 16, 2009, resulting in a serious head injury. He was admitted to Jaslok Hospital and kept in the ICU. The hospital had registered a medico-legal case and reported it to Gamdevi police station, which recorded his statement. Kishan Lal was discharged in two days.
On March 23, 2009, Kishan Lal had another fall at home, injuring his head once again. He was admitted to Jaslok in an unconscious state, where he expired on April 7, 2009 due to cardio-respiratory failure.
Later, in July 2009, his son Pravinkumar came across an individual personal accident insurance policy obtained by his deceased father from New India Assurance.
Pravinkumar lodged a claim under the policy. The insurance company rejected it, saying the claim had neither been filed in time nor had submitted documents showing cause of death. Then, Pravinkumar filed a complaint before the South Mumbai District Consumer Forum. He sought the insured amount along with a compensation of Rs 5 lakh for mental agony and Rs 50,000 towards costs. To bolster his case, he relied on the medical opinion of Dr M S Kamath.
The insurance company contested the case. Advocate Sapna Bhuptany argued that a claim under an accident policy could be entertained only in case of an accidental death, whereas Kishan Lal had died a natural death. The hospital case papers said the first fall was due to giddiness caused by a sudden onset of vertigo. The death summary of the second hospitalization records a repeat attack of vertigo. Medical history also reveals that Kishan Lal was suffering from diabetes and high blood pressure. He also had convulsions for which he was advised neurological evaluation and treatment through anti-epileptic drugs. The cause of death is certified as cardio-respiratory failure. There is no mention that death occurred due to any accident or head injuries.
In its judgment of March 11, 2015 delivered by S M Ratnakar for the bench, along with S G Chabukswar, the forum noted that the medical certificate did not reveal an accidental death. The forum differentiated between an accidental fall resulting in an injury, and a fall due to ill health. Accordingly, the forum dismissed the complaint.
Conclusion: If a person suffers a fall, resulting in death, due to violent, visible, and external means, it would be an accidental death, and a claim under an accident insurance policy will be payable. But if the fall is due to ill health, it would be considered a natural death.
Case Study: Kishan Lal Jain suffered a fall in his bedroom on March 16, 2009, resulting in a serious head injury. He was admitted to Jaslok Hospital and kept in the ICU. The hospital had registered a medico-legal case and reported it to Gamdevi police station, which recorded his statement. Kishan Lal was discharged in two days.
On March 23, 2009, Kishan Lal had another fall at home, injuring his head once again. He was admitted to Jaslok in an unconscious state, where he expired on April 7, 2009 due to cardio-respiratory failure.
Later, in July 2009, his son Pravinkumar came across an individual personal accident insurance policy obtained by his deceased father from New India Assurance.
Pravinkumar lodged a claim under the policy. The insurance company rejected it, saying the claim had neither been filed in time nor had submitted documents showing cause of death. Then, Pravinkumar filed a complaint before the South Mumbai District Consumer Forum. He sought the insured amount along with a compensation of Rs 5 lakh for mental agony and Rs 50,000 towards costs. To bolster his case, he relied on the medical opinion of Dr M S Kamath.
The insurance company contested the case. Advocate Sapna Bhuptany argued that a claim under an accident policy could be entertained only in case of an accidental death, whereas Kishan Lal had died a natural death. The hospital case papers said the first fall was due to giddiness caused by a sudden onset of vertigo. The death summary of the second hospitalization records a repeat attack of vertigo. Medical history also reveals that Kishan Lal was suffering from diabetes and high blood pressure. He also had convulsions for which he was advised neurological evaluation and treatment through anti-epileptic drugs. The cause of death is certified as cardio-respiratory failure. There is no mention that death occurred due to any accident or head injuries.
In its judgment of March 11, 2015 delivered by S M Ratnakar for the bench, along with S G Chabukswar, the forum noted that the medical certificate did not reveal an accidental death. The forum differentiated between an accidental fall resulting in an injury, and a fall due to ill health. Accordingly, the forum dismissed the complaint.
Conclusion: If a person suffers a fall, resulting in death, due to violent, visible, and external means, it would be an accidental death, and a claim under an accident insurance policy will be payable. But if the fall is due to ill health, it would be considered a natural death.
Article referred: http://timesofindia.indiatimes.com/city/mumbai/Consumers-cannot-claim-accident-insurance-if-death-is-caused-by-fall-due-to-ill-health/articleshow/46901715.cms
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